Mentally ill, behind bars

Melissa Clark sat wide-eyed and agitated in a visiting room at Cook County Jail's Cermak Hospital, rocking her right leg so vigorously that her entire body shook.

Why can't you bail me out? she repeatedly pleaded to her mother.

Carla Clark leaned forward, her forehead inches away from the partition that kept her from hugging her only daughter, and asked one question: If she bailed the 22-year-old out of jail, would the young woman take her antipsychoticmedication?

In a rambling answer, Melissa said no. Street drugs, not medication, were what made her feel better.

Clark eyed her daughter wearily. "Then I can't bail you out," she said.

Melissa's predicament tears at her mother. While jail is not an ideal place for a person needing psychiatric care, for now it might be the safest temporary option for Melissa, who has been diagnosed with bipolar disorder and schizophrenia.

In the past she has wandered the streets, committed petty crimes, overdosed on heroin and been assaulted by drug dealers. Arrested for robbery at a Whole Foods store in Chicago a year ago, she has been in jail ever since.

Soon a criminal court judge will have to decide: What do we do with Melissa?

It's the kind of problem that faces families, judges, psychiatrists, law enforcement officials and mental health advocates across Illinois, and comes up frequently as people with mental illnesses spill into jails and prisons because of a dearth of community-based services.

Cook County Jail's sizable mentally ill population has transformed the detention center into Illinois' largest psychiatric facility.

About 20 percent of the jail's 9,000 or so detainees have been diagnosed as having a mental illness. A larger, undetermined number don't have a diagnosis but show symptoms of psychiatric illness, said Cook County Sheriff Tom Dart.

"It's horribly sad on a million levels," Dart said. "This is a person who's here, not because they are quote-unquote criminal, but because they have an illness that manifests itself in doing certain acts and we are treating them like criminals."

Incarcerating people for behavior caused by their mental illnesses is costly, inhumane and doesn't make sense, mental health advocates say.

State budget cuts have made the situation worse, they say, and Dart has been considering suing the state for allowing the jail to become a dumping ground for people with serious mental illnesses.

Melissa's life began to spiral out of control during her teen years. She has cycled in and out of hospitals, jails and rehab facilities. Even though she comes from a middle-class family with resources, she is running out of options.

The family's finances have been hit hard by medical, psychiatric and legal bills, lessening relatives' ability to support Melissa. And because Melissa is an adult, she cannot be forced to participate in rehab programs or take her medications except in an emergency or under court order.

Carla Clark said jail time has been hell for her daughter, who is unable to fully understand why she is there. "I have helplessly watched her mental health deteriorate in this stressful environment," Clark said.

Melissa is being evaluated by psychiatrists to determine if she is fit for trial, but the process has been agonizingly slow.

"For what she did, it shouldn't take this long," said her brother Brandon Clark. "The waiting period is unforgivable."

The family also worries about where Melissa will go next.

In large part because of Medicaid and other funding cuts, the number of public and private psychiatric beds has plummeted over the years, and often there are waiting lists.

Even as Illinois hospitals have seen an influx of patients with mental illnesses and substance abuse problems seeking care, they have faced Medicaid cuts, inadequate private health insurance coverage and shortages of psychiatrists, said Danny Chun, a spokesman for the Illinois Hospital Association.

Hospital officials across the state "are deeply concerned and alarmed by the human consequences of delays in treatment, inadequate treatment, or no treatment at all for persons with serious mental illness or substance abuse problems," said a hospital association white paper in May.

"Families have limited options available for needed services such as substance abuse treatment, medication, community outpatient and psychiatric care," the association said. "Far too many families are waiting far too long, for far too few services."

Outpatient programs run by community agencies also have undergone deep cuts.

"It's so frustrating to know what to do and not be able to do it because of lack of money, especially because we know that investing in early prevention services is always going to be more cost-effective than the high-cost services," said Lora Thomas, executive director of the Illinois chapter of the National Alliance on Mental Illness, an advocacy group. "If services are available in the community, we can avoid visits to the emergency room -- by far, the most costly service -- and institutionalization in jails, prisons and nursing homes, or homelessness."

Terre Marshall, director of mental health at Cook County Jail, said homelessness keeps many mentally ill people from getting much needed medications and entitlements, such as Medicaid and Social Security disability income.

Left untreated, severely mentally ill people may engage in disruptive behaviors that can result in arrests for crimes that include loitering, disturbing the peace, drug possession, prostitution, retail theft and criminal trespass.

It can become a vicious cycle. Even though Melissa desperately wants to get out of jail, she already is resigned to come back because she can't imagine not abusing drugs.

Almost all of Cook County Jail's mentally ill detainees also have a substance abuse problem because they have been self-medicating with street drugs, said Dr. Jonathan Howard, jail psychiatrist.

A change last year in the way Illinois funds treatment programs has meant that people not enrolled in Medicaid are not always eligible for services that they need, some treatment providers said.

"It's been a heartbreaking year because we have not been able to serve individuals that we would have been able to help in the past," said Jill Valbuena, program director of the Thresholds Justice Program.

Melissa Clark was arrested after a skirmish with a security guard who caught her shoplifting food. She is one of an estimated 260,000 Illinoisans who have schizophrenia or bipolar disorder.

Before her illness took over, she was a cheerleader, a fan of '60s rock, a ravenous reader of fiction and biographies, a good student who enjoyed drawing. A family photo shot several years ago shows a smiling Melissa with her blond hair cascading past her shoulders and her mother beaming at her side.

A far different woman recently appeared in front of a Cook County Criminal Court judge. At a hearing last month, she appeared sullen and disoriented in blue jail garb, her hands cuffed behind her back.

Melissa, who has been arrested about a dozen times, has been unable to care for herself or hold a job.

"She has no quality of life right now," her mother said despairingly, after a recent jail visit. "She hasn't had quality of life in a long time."

After repeatedly fighting other detainees, she was transferred to the jail hospital.

Brandon Clark said it is heartbreaking to see his sister behind bars, especially since he feels that the prolonged incarceration is further eroding her mental health.

He and his mother would like to see Melissa transferred to a state psychiatric facility where she could get forced medication.

"It's such a difficult thing to say that I want someone to force medications on my sister. But after trying everything for the last seven years, it's the only option," Brandon said. "Otherwise she's going to die because she's going to overdose, somebody is going to kill her, or she's going to get hit by a car wandering around because she doesn't know what's going on."

State-operated psychiatric beds are in short supply, however.

In the 1960s there were about 35,000, according to the hospital association. That has dropped to about 730 beds for psychiatric patients who have not been charged with a crime and about 630 for people found unfit for trial or guilty but criminally insane.

The Clarks cling to hope that Melissa eventually will get the help she needs and will have a chance to live a relatively normal life. They attend her court hearings and regularly visit her in jail.

"I don't care what happens to me," said Carla Clark. "I have to help my daughter."

Jail officials, who see people like Melissa Clark all the time, say they are keenly aware of the personal tragedies, and the social costs.

"I always tell people," Dart said, " 'How is it that we, as a society, think this is good?' "